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Undone by a red nose

Phil's worst fears about PBC are about to come true thanks to a patient with acne rosacea

My next patient is an 'urgent' extra, crammed into an already full surgery. She is distressed, and clutches a tear-stained letter. She hands it over. She received it this morning and it tells her that, although laser surgery might well improve the appearance of the acne rosacea affecting her nose, the NHS is not prepared to fund it. It also tells her that if she wishes to appeal against the decision, her GP will do it for her.

I peruse the letter with a sinking heart. It does indeed assure her that her GP will be her advocate in contesting this heartless, financially motivated, healthcare-rationing decision. The one thing about the letter I am thankful for is that it doesn't identify me as the culprit. Because, dear reader, I am the guilty party.

About a month ago I received a letter about this. Somehow, my patient had been referred to a tertiary centre 20 miles away. She's got a red nose. It's not all that red. I would estimate that a good 50% of my patients have got redder noses, but she's 25 and vain and works in the cosmetics industry and she's been banging on about her red nose for six years now. At some point, one of our registrars has referred her to dermatology.

'Laser surgery would benefit your patient,' said the letter. It went on to say that the treatment was classed as cosmetic, so if I wanted my patient to have an open-ended series of sessions at £250 a shot, I should tick box A, and the cost of the treatment would be deducted from my practice's budget. If I didn't, I should tick B. Naively, I thought a couple of hip replacements would be a better use of resources, so I chose B.

And now here I am, in the uniquely uncomfortable situation of being asked to mount an appeal against my own decision.

Allow me to quote myself. Back in November I wrote this on the subject of PBC: 'The first casualty will be the trust our patients have always had in us. Up until now I could have honestly told every patient that I had done what I thought was best for them, personally. From now on, any patient might challenge me that I have done what I thought was in the best interests of my PBC cluster.'

Well, she's got me bang to rights. I don't believe her treatment is worth the money. We are at a stand. She has paid her taxes and she thinks she needs her treatment. I think she would gain some benefit, but I think my other patients need those resources more than she does. I have made a decision that she doesn't like; how will she take it when she finds out I am the stumbling block? Can she sue me? Will she sue me? What about our therapeutic relationship?

Ladies and gentlemen, at this point you would expect me to write my answer to this dilemma. I'm afraid I can't. I don't know what to do. It's a uniquely tough decision and the best I could do was say I'd get back to her in a few weeks. In the meantime, what do you think?

Advise me. The email address is at the bottom of this article. Please put a bit of thought to the matter and bear in mind that, with PBC, this is the sort of decision you are going to routinely make from now on. I am open to your suggestions.